Healthy Minds Network Stoke-On-Trent self referral form

The Healthy Minds Network provides support for people with anxiety, depression and other common mental health problems. We are the main provider of this service in Stoke-on-Trent and can now be accessed by self referral. Our three centres are based in Shelton, Burslem and Longton. We also offer appointments in many different community sites across Stoke-on-Trent.

Once your referral has been received by our team it will be checked to make sure that our service is suitable for you.

If your referral meets our criteria, we will contact you within 48-72 hours to either discuss your referral, or arrange a convenient time, date and location for an assessment appointment with one of our Psychological Wellbeing Practitioners. This face to face appointment is to discuss your main problems and explore the treatment options available to you.

 

To self refer, you can complete the forms and questionnaires below.

Alternatively, you can download the Healthy Minds Network self referral form (42 kb) [doc] and the Healthy Minds Network referral questionnaire (110 kb) [doc] and send them via email to Stoke Healthy Minds Network, or print them off and post them to:

Healthy Minds Network, Self Referrals, Unit 4, Port Vale Enterprise Centre, Hamil Road, Burslem. Stoke-on-Trent. ST6 1AW.

In addition you can call the adminstration team on 01782 524 760 and they will be more than happy to pop a form in the post for you.

For more information on self referrals to the Stoke Healthy Minds network please download Healthy Minds Network Self Referral Leaflet (147 kb) [pdf]

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Your details

Gender
Can we leave a message?
Preferred times to call you back
Can we contact you by email?

We can only accept referrals if your GP is based at one of the listed services. We apologise for any incovenience this may cause.

Presenting mental health problems

Any problems relating to;
Are you fit to engage in exercise?
Are you currently accessing any other mental health services?

Questionnaire 1

Over the last 2 weeks how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things?
Feeling down, depressed or hopeless?
Trouble falling or staying asleep or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself - or that you are a failure or have let your family down?
Trouble concentrating on things, such as reading the newspaper or watching the television?
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead or hurting yourself in some way?

Questionnaire 2

Over the last 2 weeks how often have you been bothered by the following problems:

Feeling nervous, anxious or on edge?
Not being able to stop or control worrying?
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid as if something awful might happen?

One last question